South Carolina Department of Labor, Licensing and Regulation South Carolina Board of Long Term Health Care Administrators

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1 South Carolina Department of Labor, Licensing and Regulation South Carolina Board of Long Term Health Care Administrators 110 Centerview Dr. Columbia SC P.O. Box Columbia SC Phone: Fax: COMMUNITY RESIDENTIAL CARE FACILITY ADMINISTRATOR PROVISIONAL REQUIREMENTS AND INSTRUCTIONS EXAM REQUIREMENTS: Upon approval of the application for community residential care facility administrator applicant is required to take the national and state examinations to become licensed in South Carolina. Board staff will send qualified applicants, by mail or , the Examination Approval Notice. This notice provides instructions on how to register for the examination(s). The applicant will have thirty days as stated in the approval letter to register for the national and/ or state exam with NAB. Upon registering for the exam, an ATT (Authorization to Test letter) will be ed to the applicant with instructions on setting up the test dates for the examination(s). The applicant will be given a 60 day window with the expiration date to take the examination(s) The Board will receive exam results electronically from NAB (National Association of Boards of Long Term Health Care Administrators) within two weeks after the applicant takes the examination(s). The exam report will be sent to the applicant electronically or by mail. Community Residential Care Facility Administrator The national examination for Community Residential Care Facility Administrators consists of 150 multiple-choice questions. The national exam is based on the National Association of Boards of Long Term Health Care Administrators study guide material. The RC/AL Study Guide can be ordered from the NAB website at order form. The state exam for Community Residential Care Facility Administrators consists of 50 multiplechoice questions. The state exam is based on S.C. Regulation 61-84, Standards for Licensing Community Residential Care Facilities established by the Department of Health and Environmental Control-Division of Health Licensing. Please contact DHEC at (803) for the regulation book or go to Examination fees are set by the National Association of Boards for Long Term Care Administrators: National and SC State $500 National only $325 SC State only $190 The examinations are administered on computer at PSI Testing Centers throughout the United States. PROVISIONAL INSTRUCTIONS A Provisional license may be issued provided that the applicant meets the pre-examination requirements and completes the steps for the application and examination process beginning with Step 1. The provisional license fee is separate from the application fee. An applicant will pay the $250 provisional license fee after receiving notice that the application has been approved. A Provisional license will be issued upon receipt of the fee. A provisional license will expire 90 days from issue or upon the issue of an initial license, whichever occurs first.

2 A Provisional license is issued in the event of an unexpected vacancy caused by the death or departure of an administrator, or similar event. The owner of the facility must submit a letter requesting the applicant be appointed the administrator which states all of the following: 1. The need for a provisional license; 2. The name of the appointed administrator; 3. The date of the appointment and; 4. A specific request that the board issue a provisional license to the named administrator. If the provisional administrator does not pass both the national and South Carolina state examinations, the facility must obtain the services of a consultant administrator for a minimum of sixteen (16) hours per month until the applicant passes the exam(s). The consultant administrator must have a minimum of two years of experience operating a facility. If the applicant fails the examination(s) the second time, the provisional license will be terminated thirty days after the applicant is notified of the examination score(s). If any applicant fails to present themselves for the examination(s), the provisional license will terminate at the close of business on the day of the examination(s). CRIMINAL BACKGROUND CHECK (CBC): A person applying to become an administrator must undergo a state fingerprint review to be conducted by the State Law Enforcement Division and a federal fingerprint review to be conducted by the Federal Bureau of Investigation. The Board may deny an applicant for certain crimes. The criminal background check should not be processed until after your application has been received by the Board. See Criminal Background Check Notice. EMPLOYMENT REFERENCE FORM: Fill out your name on the employment reference form (pdf) and to your current or former employers to have completed and submitted to the Board. A link for this form may be found at: CHARACTER REFERENCE FORMS: Submit three character references (cannot be related by blood, marriage or employer/supervisor. Forms can be mailed by person given the reference or by applicant. A link to be formed may be ed to the reference, this link can be found at:

3 APPLICATION INFORMATION: Include with your application: Check or money order (no cash) in the amount of $100 made payable to LLR-Board of Long Term Health Care Administrators. Application fee is non-refundable. A returned check fee of up to $30, or an amount specified by law, may be assessed on all returned funds. Copy of your valid Driver's License, State Issued ID, Passport or Military ID Copy of your social security card Three Character Reference Forms (You or the reference may submit.) Have submitted directly to the Board office address above from the issuing agent: College Transcripts License Verification, if applicable Score Transfer, if applicable Employment Reference Form (For each employer) Must have job description attached Your application is valid for one year from the date of the application. You may check the status of your application online by visiting the Board s website at and select Application Status.

4 South Carolina Department of Labor, Licensing and Regulation South Carolina Board of Long Term Health Care Administrators P.O. Box Columbia SC Phone: Fax: Criminal Background Check (CBC) Instruction Sheet An applicant for a license to practice medicine in South Carolina shall be subject to a criminal history background check as defined in Section of the Medical Practice Act. This process requires you to furnish a full set of fingerprints and additional information required to enable a criminal history background check to be conducted by the State Law Enforcement Division (SLED) and the Federal Bureau of Investigation (FBI). These services are provided by IdentoGO Centers and are operated by MorphoTrust USA. Residents of South Carolina should go online to schedule for fingerprinting services: or call (866) for assistance in scheduling. Scheduling services will provide detailed information of forms of identification that will be required. If you are a non-resident of South Carolina and do not reside in an area near South Carolina, please follow the Non- Resident Card Scan Processing Procedures below. Non-Resident Card Scan Processing Procedures For applicants that reside out of South Carolina who wish to use the IdentoGO/Morpho Trust USA Centers, you may use these centers that are located in South Carolina only. If an applicant does not reside near South Carolina, they must complete and submit the fingerprint cards by following the directions below. This program utilizes advanced scanning technology to convert a traditional fingerprint card (hard card) into an electronic fingerprint record. The section below details the procedures for submitting fingerprints to the MorphoTrust card scan department. Applicant should contact IdentoGO/MorphoTrust ( ) to verify the current fee to submit. Applicants should obtain a set of fingerprints from a local law enforcement agency or other entity that provides fingerprinting services. These fingerprint cards may be either traditional ink rolled fingerprints or electronically captured and printed fingerprint cards. Fingerprints may be submitted on FBI applicant cards. The applicant may call or the Medical Board to have the FBI applicant cards mailed to them. Phone: or contactllr@llr.sc.gov. Due to agency specific information, MorphoTrust USA does not provide fingerprint cards to applicants. Applicant should ensure the fingerprint cards are completely filled out. Required information includes: o ORI Number: SCBDNRCAZ - o Social Security Number Long Term Care o Date of Birth o Full Name o Home Address o Sex, Height, Weight, Hair Color and Eye Color o Place of Birth (State or Country Only) o Reason fingerprinted o Citizenship Mail the fully completed card and applicable fee (Include full name of applicant on the check) to: MORPHOTRUST USA ATTN: SC Card Scan 6840 Carothers Parkway Ste 650 Franklin TN Follow-up calls and questions on the processing of a fingerprint card should be made directly to IdentoGO/MorphoTrust at (866) and speak to a customer service representative. DO NOT return fingerprint card or fingerprint processing fee in with your application or to the Board of Medical Examiners. This will delay the processing of your application.

5 NONCRIMINAL JUSTICE APPLICANT S PRIVACY RIGHTS As an applicant who is the subject of a national fingerprint-based criminal history record check for a noncriminal justice purpose (such as an application for a job or license, an immigration or naturalization matter, security clearance, or adoption), you have certain rights which are discussed below. You must be provided written notification 1 that your fingerprints will be used to check the criminal history records of the FBI. If you have a criminal history record, the officials making a determination of your suitability for the job, license, or other benefit must provide you the opportunity to complete or challenge the accuracy of the information in the record. The officials must advise you that the procedures for obtaining a change, correction, or updating of your criminal history record are set forth at Title 28, Code of Federal Regulations (CFR), Section If you have a criminal history record, you should be afforded a reasonable amount of time to correct or complete the record (or decline to do so) before the officials deny you the job, license, or other benefit based on information in the criminal history record. 2 You have the right to expect that officials receiving the results of the criminal history record check will use it only for authorized purposes and will not retain or disseminate it in violation of federal statute, regulation or executive order, or rule, procedure or standard established by the National Crime Prevention and Privacy Compact Council. 3 If agency policy permits, the officials may provide you with a copy of your FBI criminal history record for review and possible challenge. If agency policy does not permit it to provide you a copy of the record, you may obtain a copy of the record by submitting fingerprints and a fee to the FBI. Information regarding this process may be obtained at If you decide to challenge the accuracy or completeness of your FBI criminal history record, you should send your challenge to the agency that contributed the questioned information to the FBI. Alternatively, you may send your challenge directly to the FBI. The FBI will then forward your challenge to the agency that contributed the questioned information and request the agency to verify or correct the challenged entry. Upon receipt of an official communication from that agency, the FBI will make any necessary changes/corrections to your record in accordance with the information supplied by that agency. (See 28 CFR through ) 1 Written notification includes electronic notification, but excludes oral notification. 2 See 28 CFR 50.12(b). 3 See 5 U.S.C. 552a(b); 28 U.S.C. 534(b); 42 U.S.C , Article IV(c); 28 CFR 20.21(c), 20.33(d) and 906.2(d).

6 PRE-EXAMINATION REQUIREMENTS FOR LICENSURE COMMUNITY RESIDENTIAL CARE FACILITY ADMINISTRATORS (CRCF) SC Code of Law Qualifications and Requirements The Board shall issue a community residential care facility administrator license to a person who submits evidence satisfactory to the board that the person: 1. Must be 21 years of age; 2. Has not been convicted of any criminal act that is relevant to the practice of Community Residential Care Facility administration, including financial misconduct or physical violence; 3. Be of reputable and responsible character and is of sound physical and mental health sufficient to perform the duties of a Community Residential Care administrator. Education and Experience 1. Has a non-health related associate degree or is a licensed practical nurse with at least one year of on-site work experience of at least 384 hours with supervisory and direct resident care responsibilities under the supervision of a licensed Community Residential Care Facility Administrator; or Explanation of requirements: Applicant must have a non-health related association degree with on-site work experience in a licensed CRCF of at least 384 hours, with supervisory and direct resident care responsibilities under the supervision of a licensed CRCF Administrator. All of the above is required to be obtained in at least one year. 2. Has a health related associate degree with at least nine months of on-site work experience of at least 288 hours with supervisory and direct resident care responsibilities under the supervision of a licensed Community Residential Care Facility Administrator; or Explanation of requirements: Applicant must have a health related association degree with on-site work experience in a licensed CRCF of at least 288 hours, with supervisory and direct resident care responsibilities under the supervision of a licensed CRCF Administrator. All of the above is required to be obtained in at least nine months. 3. Has a baccalaureate or higher with at least six months of on-site work experience of at least 192 hours with supervisory and direct resident care responsibilities under the supervision of a licensed Community Residential Care Facility Administrator. Explanation of requirements: Applicant must have a baccalaureate or higher with on-site work experience in a licensed CRCF of at least 192 hours, with supervisory and direct resident care responsibilities under the supervision of a licensed CRCF Administrator. All of the above is required to be obtained in at least six months Additional combination of education and experience acceptable by the Board; Criminal Background Check; Completion of probation or parole. A. In addition to the requirements in South Carolina Code Ann. Section (B), the following combination of education and experience shall be acceptable for consideration of a community residential care facility administrator: (1)A South Carolina licensed nursing home administrator that has been a practicing nursing home administrator for two or more years shall not be required to have on-site work experience at a community residential care facility under the supervision of a licensed community residential care facility administrator.

7 STATE OF SOUTH CAROLINA DEPARTMENT OF LABOR, LICENSING AND REGULATION VERIFICATION OF LAWFUL PRESENCE IN THE UNITED STATES AFFIDAVIT OF ELIGIBILITY Pursuant to Section , et seq. of the South Carolina Code of Laws (1976, as amended), the Department of Labor, Licensing and Regulation must verify that any person who applies for a South Carolina license is lawfully present in the United States. Complete and sign this affidavit of eligibility. The information provided is subject to verification. Section A: LAWFUL PRESENCE in the United States. The undersigned, of (Print clearly First, Middle, and Last name) (Home Address, City, State, and Zip Code) being first duly sworn deposes and states as follows: Check only one box: 1. I am a United States citizen; or 2. I am a Legal Permanent Resident of the United States eighteen years of age or older; or 3. I am a Qualified Alien or non-immigrant under the Federal Immigration and Nationality Act, Public Law , eighteen years of age or older, and lawfully present in the United States. 4. Other: Please submit any documentation that supports this status. Date of Birth: _ Alien Number: _ I-94 Number: (If you checked number 2, 3, or 4 you must attach a copy of your immigration documents. See instruction sheet for a list of accepted immigration documents.) Section B: ATTESTATION. I understand that in accordance with section of the South Carolina Code of Laws, a person who knowingly and willfully makes a false, fictitious, or fraudulent statement or representation in an affidavit shall, in addition to other sanctions imposed by this State or the United States, be guilty of a felony, and upon conviction must be fined and/or imprisoned for not more than 5 years (or both). I understand that the representations made in this Affidavit shall apply through any license(s) or renewals issued, and that I shall have an affirmative duty to immediately advise the Department of Labor, Licensing and Regulation of any change of my immigration or citizenship status. I swear and attest the information contained herein is true and correct to the best of my knowledge. I understand that under South Carolina law, providing false information is grounds for denial, suspension, or revocation of a license, certificate, registration or permit. Signature of Affiant SWORN to before me this day of, 20 Notary Signature Print Name Notary Public for My Commission Expires: Rev:

8 INSTRUCTION SHEET FOR COMPLETING AFFIDAVIT OF ELIGIBILITY CHECK box 1: If you are a United States Citizen by birth or naturalization CHECK box 2: If you are a Legal Permanent Resident and you are not a U.S. Citizen, but are residing in the U.S. under legally recognized and lawfully recorded permanent residence as an immigrant. PROVIDE A COPY OF ALL IMMIGRATION DOCUMENTS. CHECK box 3: If you are a Qualified Alien. You are a Qualified Alien if you are: An alien who is lawfully admitted for residence under the INA. An alien who is granted asylum under Section 208 of the INA. A refugee who is admitted to the United States under Section 207 of the INA. An alien who is paroled into the United States under Section 212(d)(5) of the INA for a period of at least 1 year. An alien whose deportation is being withheld under Section 243(h) of the INA (as in effect prior to April 1, 1997) or whose removal has been withheld under Section 241(b)(3). An alien who is granted conditional entry pursuant to Section 203(a)(7) of the INA as in effect prior to April 1, An alien who is a Cuban/Haitian Entrant as defined by Section 501(e) of the Refugee Education Assistance Act of An alien who has been battered or subjected to extreme cruelty, or whose child or parent has been battered or subject to extreme cruelty. PROVIDE A COPY OF ALL IMMIGRATION DOCUMENTS. ACCEPTED IMMIGRATION DOCUMENTS: Unexpired Reentry Permit (I-327) Permanent Resident Card or Alien Registration Receipt Card With Photograph (I-551) Unexpired Refugee Travel Document (I-571) Unexpired Employment Authorization Card Which Contains a Photograph (I-766) Machine Readable Immigrant Visa (with Temporary I-551 Language) Temporary I-551 Stamp (on passport or I-94) I-94 (Arrival/Departure Record) in Unexpired Foreign Passport I-20 (Certificate of Eligibility for Nonimmigrant, F-1, Student Status) DS2019 (Certificate of Eligibility for Exchange Visitor, J-1, Status) Rev:

9 South Carolina Department of Labor, Licensing and Regulation South Carolina Board of Long Term Health Care Administrators 110 Centerview Dr. Columbia SC P.O. Box Columbia SC Phone: Fax: LTHC SIGNATURE AFFIDAVIT CERTIFICATION I,, am the person described and identified, in all documents presented in support of this application. I have carefully read the questions in the foregoing application and have answered them completely, without reservations of any kind and I declare that all statements made by me herein are true and correct. Should I furnish any false or incomplete information in this application I hereby agree that such act shall constitute the cause for denial or revocation of my license to practice nursing home administration and/or community residential care facility administration in South Carolina. Applicant s Signature: Date: Sworn to and subscribed me this day of, 20. Notary Signature: Print Notary Name: Notary Public for the State of: SEAL Commission Expiration Date: